A patient has died as a result of swallowing a tablet while it was still in its blister packaging. The tragic death was caused by perforation of his gut by the blister packaging. The tablet in its blister packaging was included in the patient’s medicines compliance aid. Pharmacists are advised to refer to the RPS guidance: Improving patient outcomes: the better use of multi-compartment compliance aid.
Our guidance states:
“Do not repackage MCA by inclusion of the original strip or blister packaging. Medicines should not be repackaged within MCA in their original strip or blister packaging as there have been reports of patients swallowing the medicine and its packaging resulting in gastric perforation or pelvic abscesses. The MCA package should be sealed as soon as possible after filling.”